To love or not to love: Debating a romantic HCP-patient relationship

To love or not to love: Romantic love may be simple, intoxicating and passionate – but, to a HCP, if the lover is a patient, it can be complex and unethical.

Can healthcare professionals (HCPs) date patients?

The simple answer is: no. But, the complex answer would be "maybe, it depends".

Romantic love may be simple, intoxicating and passionate. But, to a HCP – if the lover is a patient – it can be complex and unethical. Contrary to popular culture – where fairy-tale HCP-patient relationships are portrayed in popular TV shows like Grey’s Anatomy, Scrubs and House – healthcare associations around the world explicitly state that, romantic relationships or sexual contact between HCP and patient cannot happen. However, a grey area exists for relationships that might develop later.

To be debated: Status of professional relationships

The General Medical Council (GMC) in the UK attempted to address this in 2013, issuing guidelines that clarified the risks of doctors embarking on a romance with former patients.

“If you are considering whether to pursue a personal relationship with a former patient, you must use your professional judgement” the GMC stated. But, it also could not specify how long HCPs should wait after the professional relationship ceases, to pursue a personal relationship.

Some ethicists argue that the specialities of the profession is a crucial factor to take into account. Some specialities by nature have a more intimate relationship, that may make the patient more vulnerable.

Similarly, the American Medical Association (AMA) highlights that any prior doctor-patient relationship may unduly influence the patient. Therefore, the pursuit of such a relationship is unethical if the doctor “uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship.”

Would this mean that such relations might not be unethical if the doctor does not exploit aspects of the professional relationship? There is also no statement regarding former lovers becoming current patients.

No exceptions in Malaysia

Taking a leaf out of international standards, the Malaysian Medical Council’s (MMC) Code of Professional Conduct is even stricter by extending the ban on personal relationships to members of the patient’s family. Yet, this does not address the obscurity of the guidelines.

Examining the details of the guidelines, Mr Darryl Goon, Partner of Raja, Darryl & Loh, a reputable law firm in Malaysia asks, “What then is the ambit of the term “family” in the context of MMC’s Code of Professional Conduct?”

“Generally, the nexus between those who are regarded as family members may arise by reason of consanguinity (that is to say related by blood) or through marriage.”

“The Code is not clear as to who falls within the definition of “family”. Without any qualification given to the term “family”, one may infer that the intention is to confer the widest meaning that may legitimately be attributed to the term,” he adds.

“It depends on the circumstances, but you got to extract some principle. Unfortunately, we don't have any reported cases in Malaysia so it is difficult for us to say where's the line to be drawn,” says Mr Goon.

As for dentists and nurses, the Malaysian Dental Council’s (MDC) Code of Professional Conduct and the Nursing Board Malaysia Code of Professional Conduct for Nurses, both state that there must be no emotional or sexual relationship with a patient under his or her care.

“The guidelines expressed in these ethical codes do not distinguish between the mere status of the individuals – patient and HCP – and whether there is still in existence, a professional relationship between the HCP and his or her patient,” Mr Goon elaborates.

Such emphasis meant that “as long as there is or has been a professional relationship between HCP and patient, the restriction in ethical codes will apply.”

Is there a room for change?

From an administrative justice standpoint, the rules and guidelines seem simple to administer and superficially unquestionable. But setting ethical boundaries is rarely perfect – as the rules address extremely complicated human behaviours. The inflexibility of the law weights unfairly on some parties, and is sometimes forcibly applied on cases whose circumstances do not fit.

Take for example, a single doctor practicing in a rural small town. As the doctor is likely to be the main caregiver of the town, almost anyone is a potential patient. Therefore, if said doctor starts courting a local man or woman, he or she would have run afoul of the rules – leaving the doctor an option to date residents of the next town only.

Going one step further, suppose the doctor and a particular local resident consents to a relationship, fully understanding the potential conflict of interest if the doctor prescribes penicillin for a strep throat infection, should the doctor’s license be taken action against? Does the local resident need to ask for an out-of-network referral?

Note that it is not the geographic reality, but rather the contractual restriction that forms the ethical bind.

“The nature of this issue is very circumstantial. I have yet to hear of any incidences, neither have we read anything in the press. But, the bottom line for me, is whatever happens, it should not be in your place of practice,” says Dr Ravichandran.

Dr Ravichandran R. Naidu, President of the Malaysian Medical Association suggests a more liberal approach, “I don’t see why it is unethical, if it is a willing relationship, which happens outside the practice, I can’t see why not.”

He emphasises that “it should not happen in the clinic, as the place of practice – at least for me – is very sacred.”
“I think doctors are matured enough and can think for themselves… Relationships basically mean that it is willing to both parties,” he concludes.

Ethical concerns dictate a case-by-case review

However, others such as Dr Ng Woan Tyng, President of the Malaysian Dental Association, beg to differ.

“The concern is the ethical risk. What if a relationship turns sour?” she questions, “The patient’s personal data should be protected and might not be protected at that point of time. The patient might turn on the HCP.”

Echoing Dr Ng’s take on the issue, Professor Dato’ Dr Ishak Abdul Razak, Representative of MDC, is more concerned on the reputation of the professions.

“If I have a patient coming into my clinic, and I start to date this patient, yet she still comes to see me. To the eyes of the public, it may not look professional,” he explains.

“They may question, ‘is this doctor doing the right thing or not?’,” he adds.

Professor Ishak stands with Dr Ng on her ethical concerns, suggesting either the termination of the either the professional or personal relationship if such a situation arises.

Developing trust for HCPs: A societal issue

Perhaps the cultural mindset of society plays a part in the issue. As Mr Goon puts it, “The rationale for the prohibition of personal or sexual relationships between a HCP and his or her patient is premised upon the appreciation that a HCP can have undue influence over his or her patient and societies’ need to be able to trust HCPs.”

“In this day and age, it would seem that the ethical codes, as expressed in relation to this topic, seem perhaps somewhat stringent,” he says.

He argues that society could be more open-minded and not frown upon personal relationships that arise after the professional relationship between HCP and patient has ceased to exist.

“Perhaps the test should be premised on whether there is, present, a real risk that the patient was unduly influenced and/or was vulnerable or whether the position of being a physician was taken advantage of by the HCP to secure a personal relationship,” he illustrates.

The practical problem that is attached to the state of vulnerability of the patient is, how long must the HCP-patient professional relationship be ceased before a personal relationship can be pursued?

This way, it allows room for genuine relationships between a HCP and a former patient when the professional relationship has ceased and the danger of undue influence is no longer present – for example, what is done in the UK or some states in the US.

Again, the GMC does not specify appropriate length of time after which the professional relationship ceases, but interestingly California does.

“There it is provided that there be a cooling off period of two years from the cessation of the professional relationship whereupon a HCP is then permitted to engage in a personal relationship with a former patient,” states Mr Goon.

But what is the basis for that?

The complexity of a HCP-patient romance deserves a sophisticated and daring ethical analysis. The current cynical view that love cannot exist and sex is usually abusive and transient, between people of different positions of power should be reviewed.

Whilst professional standards may seem perfectly rational and make common sense, love clearly obeys different rules. MIMS

"The heart has its reasons that reason does not know."
-- Blaise Pascal (1623-1662)

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